The debate around tobacco control in Pakistan, like most countries in the Eastern Mediterranean Region, is usually limited to raising the price of tobacco products and controlling underage smoking. While these arguments given around tobacco control appear plausible at a glance, they tend to miss out the most important stakeholders affected by the debate, smokers! What is that motivates smokers to begin smoking? How can we target the reasons which lead smokers to take up this habit? Do they need medical advice to help them cope with the effects of nicotine withdrawal? When it comes to smoking cessation, the discourse needs a radical shift by taking onboard the needs of smokers to help them quit smoking.
Smoking Cessation: The Global Perspective & Apathy in Pakistan
Before we dwell into the policies and outlook of smoking in Pakistan, let’s review the global perspective on smoking cessation. According to WHO, tobacco kills more than 8 million people annually, out of which 7 million are a direct result of smoking tobacco and 1.2 million due to exposure to secondhand smoke. WHO estimates 80% of the estimated 1.3 billion tobacco users from low-middle income countries.
In Pakistan, the debate around smoking is often shrugged off by the average smoker, citing that one of their relatives who has been smoking for several years are still alive and kicking. Little does that argument ever consider the quality of life, health issues and the increase in other factors contributing heavily to further exacerbate the deteriorating health of smokers, be it the annual smog in Pakistan’s big cities and more recently, Covid-19.
This message by Dr. Derek Yach, President of the Foundation for a Smoke Free World, is worth a watch to understand the importance of smoking cessation.
The Need to Take Smokers on Board for Smoking Cessation
The success rate for smokers quitting smoking in Pakistan is merely 2.6%, which is deemed as one of the lowest in the world. Pakistan ratified the WHO Framework Convention on Tobacco Control (FCTC) on 3 Nov 2004. This was the same year the FCTC was introduced for ratification. However, the progress on the convention in Pakistan has been mixed. While the price of tobacco products, particularly cigarettes, have seen a steady increase over the years, the provision of smoking cessation services in Pakistan has been next to none. This is a key area highlighted by the FCTC under Article 14 which Pakistan lags behind. Article 14 instructs member states to take effective measures to promote tobacco cessation.
Smokers have never been part of the tobacco control policies in Pakistan. Around 27% smokers in Pakistan at least make one attempt in a year and out of them 2.8% quit smoking successfully. A few years ago, smoking cessation clinics were opened in one of the leading hospitals in Islamabad. However, these clinics soon fizzled out.
There is a global debate around Harm Reduction Products (HRPs) such as e-cigarettes and nicotine replacement therapy, however this is often opposed by people on the other side of the debate, who consider them as bad as tobacco smoking. On the contrary, there are numerous researches and policy initiatives have proven that HRPs can be effective in smoking cessation. While countries like Canada, UK and New Zealand have been encouraging smokers to switch to vaping in order to quit smoking, Australia has recently proposed a vaping ban which has been dubbed by some analysts as ‘draconian’. The new law, if implemented would see vapers facing $220,000 fine for using nicotine vaping products without a doctor’s prescription.
Tobacco Farming and the Need for Alternative Crops
In June 2020, the Government of Pakistan imposed 100% Federal excise duty (FED) on cigarettes, cigars and other tobacco products. However, much needs to be done to enable existing smokers to quit their addictive habit. Tobacco control efforts become even more trivial at the policy level due to the fact that Pakistan earns a significant amount from tobacco export. Pakistan has a market share of around $25 million out of the $80 billion share in the world tobacco trade. As per statistics of FY19, at least 108,000 tons of tobacco was exported by Pakistan to around 26 countries. The estimated revenue generated through these exports stands at $24.4 million.
In order to promote smoking cessation in Pakistan, another voice that needs to be desperately heard is of tobacco farmers. Unless government policies provide them with lucrative alternatives, tobacco farming will continue to grow and strain the already fragile national health system due to smoking related illnesses. According to a journal published by Pakistan Journal of Medical Sciences, titled ‘An overview of smoking practices in Pakistan’, smoking remains a major public health issue and one of the leading risk factor making up to 87% cases of lung carcinoma detected in smokers. The journal also states that people over 40 or more have a 60 times increased risk of suffering from lung cancer. In the wake of a variable such as COVID-19 the situation becomes even more diabolical, as smokers have been known to be more at risk of the disease than non-smokers.
Reinvigorating the Tobacco Control Discourse in Pakistan
In the wake of a rather stagnant scenario in Pakistan, Pakistan Alliance for Nicotine and Tobacco Harm Reduction (PANTHR) is reinvigorating the smoking cessation debate in the country. PANTHR and its Eastern Mediterranean Chapter PANTHR EMR has called for a multi-faceted approach to tackle tobacco smoking in Pakistan. Along with raising the cost of tobacco products, PANTHR proposes a government led policy which provides easy and affordable access to smoking cessation clinics. Smokers who look to quit undergo a number of health-related problems which need to be medically addressed with professional advice and sometimes, some psychological support, which smoking cessation clinics can offer. Furthermore, there needs to be a sustained policy to reduce tobacco farming by allowing farmers to switch to alternative cash crops.
Last but not least, there needs to be a policy review regarding the use of Harm Reduction Products (HRPs), which are currently not affordable for the average smoker. HRPs as compared to dirt cheap cigarettes leaves little opportunity cost for the average smoker. HRPs can be a good way to transition smokers from tar-based cigarettes to alternatives which can help them in smoking cessation.
A policy that does not consider the voice of key stakeholders is likely to result in a less than successful outcome. Smokers left out in the dark, without guidance regarding cessation options is not going to reduce the number of people hooked to tobacco smoking in Pakistan. Not to mention the tobacco control debate in Pakistan is often quite stagnant, with anyone ever hardly mentioning smoking cessation. This leads to a rather futile debate, where merely increasing taxes is deemed as the swiss army knife for tobacco control, without considering the motivations of the average smoker and targeting the very mindset which leads to smoking. The NGOs working on smoking cessation are doing a commendable job under limited resources, however, reinvigorating the smoking cessation debate can help improve the outcomes of projects aimed at targeting smokers to quit smoking.
Taking smokers onboard decisions will help generate interest among them regarding tobacco control policies and also enable policy makers to consider the point of view of smokers. This not only includes those looking to quit smoking and the problems they face in doing so but also those who are apathetic towards the very thought of quitting smoking. In the case of the latter, it would open up a doorway to explore their motivations and misconceptions in order to better educate them.
Note: Pakistan Alliance for Nicotine and Tobacco Harm Reduction (PANTHR) is looking for members, including smokers who might be willing to become a part of the smoking cessation discourse. You can join PANTHR by sending a membership request.